Aetna gets partial win in cancer coverage lawsuit

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Aetna got a partial win in a proposed class-action lawsuit that claims the health insurer wrongfully denied coverage for a cancer treatment called proton beam radiation therapy, according to court documents

The lawsuit, filed by Sharon Prolow, was brought on behalf of beneficiaries of Employee Retirement Income Security Act plans. The lawsuit claims Aetna violated its fiduciary obligations and wrongfully denied coverage of proton beam radiation therapy for breast cancer as an experimental or investigational treatment.

In his opinion and order on Ms. Prolow's lawsuit, filed in the U.S. District Court for the Southern District of Florida Jan. 4, U.S. District Judge Kenneth Marra said Ms. Prolow must amend her complaint for it to progress. Mr. Marra said Ms. Prolow must remedy her breach of fiduciary duty claim, and an amended claim must make it clear that a breach of fiduciary duty doesn't rest on an assertion of unpaid benefits by Aetna.

While some insurers have begun covering proton beam radiation therapy for certain cancers — for example, Medicare generally covers the treatment — it is not uniform across the commercial insurance industry. Aetna is facing another lawsuit that claims the insurer systematically denies coverage for proton beam therapy.

Aetna's proton beam radiotherapy policy, last reviewed in October 2020, outlines when the insurer considers the treatment medically necessary. In the bulletin, Aetna said it considers proton beam radiotherapy "experimental and investigational" for breast cancer in adults over age 21 "because its effectiveness for these indications has not been established."

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